hello and welcome to chapter 36 geriatric emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the physiologic and psychological changes that occur with the aging process you will also learn and understand the types of illness and injuries common in the geriatric population and you'll understand the gems triangle use of advanced directives and signs and symptoms of elder abuse bariatrics is the assessment and treatment of disease in a person who is age 65 or older it is projected that between 2012 and 2050 the population age 65 years and older is expected to nearly double bariatric patients present as a special challenge for health care providers because the classic presentation of illness and injuries are often altered by the presence of chronic conditions multiple medications and the physiology of aging so let's talk about some generational considerations it's important to understand and appreciate how the life of an older person might differ from yours it takes time and patience to interact with an older person always treat the patient with respect make every attempt to avoid ageism the stereotyping of older people that often leads to discrimination older people can stay fit be active even though they are not able to perform at the same level as they did in their youth so let's talk about communication with older adults okay effective verbal communication skills are essential to the successful assessment and treatment of an older patient communication with older people can be challenging and challenges and communication abilities accompanying aging such as dementia and other disease so let's talk about communication techniques in general when caring for older individuals use their name to communicate with them if you do not know their name you sir or ma'am asking the patient how he or she prefers to be a dress can build trust and when you interview an older patient the following techniques should be used you want to identify yourself you want to be aware of how you present yourself you want to look directly at the patient at the eye level and ensure good lighting and speak slowly and distinctly have one person talk to the patient and ask only one question at a time do not assume that all older patients are hard of hearing give the patient time to respond unless the condition appears urgent listen to the answer the patient gives you explain what you're going to do before you do it and do not talk to the patient in front of him or her as though the patient is not there okay so let's talk about some common complaints and the leading disease of death or 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 a simple rib fracture in an 80 or 90 year old can cause or result in pneumonia or even death a hip fracture from a low mechanism fall is common in older people and may have dire consequences hip fractures are more likely to occur when bones are weakened by osteoporosis or infection and sedimentary behavior while healing can predispose a patient to pneumonia and blood clots many older people who experience hip fractures do not re return to their pre-injury level of activity okay and so on this chart it shows some of the common conditions and the leading causes of death in geriatric patients there are also changes in the body human growth and development peaks at it in the late 20s and early 30s at which point the aging process begins the aging process is inevitable it's accompanied by changes in physiologic functions such as the decline and function of the liver and kidneys all tissues in the body undergo aging the decrease in function capacity of various organ systems in normal can is normal and can affect the way in which a patient responds to illnesses so let's first talk about changes in the respiratory system for and we're going to talk about the anatomy and physiology okay so age-related changes can predispose an older adult to respiratory illnesses what happens is there's weakening of the airway musculature and it can cause decreased breathing capacity alveoli can become enlarged and elasticity decreases making it harder to expel air chemoreceptors slow with age and this causes the body to respond more slowly to hypoxia and loss of mechanisms that protect the upper airway include decreased cough and gag reflexes so let's first talk about pneumonia it's a chronic lower respiratory disease such as influenza and pneumonia are the top five causes of geriatric death inflammation infection of the lung from bacteria viral or fungal causes it's a leading cause of death from infection in older americans older than 65 years old and aging causes some immune suppression and increases the risk of contracting infections like pneumonia increased mucus production pulmonary secretions and the inflammatory effects of infection all interfere with the ability of the alveoli to oxygenate the blood management of pneumonia is the same for any patient however maintain a high index of suspicion for any geriatric patient with signs and symptoms of pneumonia pulmonary emboli so causes a sudden blockage of an artery by a venous clot a patient with a pulmonary emboli or embolism will present with shortness of breath and sometimes chest pain it can be confused with a cardiac lung or muscular skeletal problem so let's talk about the risk factors living in a nursing home or recent hospitalization for medical illness or surgery trauma cancer a history of blood clots or heart failure the presence of a pacemaker or central venous catheter paralyze extremities obesity smoking or recent long distance travel are all risk factors patients present with tachycardia a sudden onset of dyspnea shoulder pain back or chest pain cough syncope in patients in whom the clot is larger and anxiety apprehension sometimes a low-grade fever leg pain redness and unilateral penile pedal edema fatigue cardiac arrest in worst case scenario treatment should focus on the airway ventilatory and circulatory support supplemental oxygen and ventilatory support may be needed okay so we've talked about the respiratory changes now we're going to talk about the cardiovascular system changes in particular right now we're going to talk about the anatomy and physiology changes okay so the heart hypertrophies with age probably in response to the chronically increased afterload imposed by stiffening of the blood vessels so over time cardiac output declines mostly as a result of decreasing stroke volume and arterial sclerosis contributes to systolic hypertension which places an extra burden on the heart the ability to speed up contractions increase contraction strength and constrict or narrow blood vessels is decreased because of stiffer vessels over time cardiac output declines mostly as a result of decreasing stroke volume and arterial sclerosis contributes to systolic hypertension which places an extra burden on the heart so the figure on this slide shows atherosclerosis the buildup of fat and cholesterol in the arteries older people are also at an increased risk for from formation of an aneurysm severe blood loss can occur when the aneurysm ruptures the blood vessels become stiff which result in a higher systolic blood pressure then stiffening and generation degeneration of the heart valves that may impede blood flow into the heart in the now the electrical conduction system of the heart undergoes changes leading to an abnormal heart rate or rhythm and orthostatic hypotension is a drop in blood pressure with a change in position the body is less able to adapt to rapid postural changes venous stasis can cause clots to develop in the veins leading to deep vein thrombosis or pulmonary emboli loss of proper function of the veins in the legs that normally carry blood back to the heart then myocardial infarcts so the classic symptoms of a heart attack are often not present in geriatric patients as many as one-third of older patients have silent heart attacks and because the usual chest pain is not present more common in women and patients with diabetes signs and symptoms of cardiovascular disease include dipstick epigastric and abdominal pain loss of bladder and bowel control nausea and vomiting weakness dizziness lightheadedness and syncope fatigue and confusion other signs and symptoms include diaphoresis pale cyanotic or mottled skin abnormal or decreased breast sounds increased peripheral edema and how we're going to treat it is airway ventilatory and circulatory support administer aspirin or assist a patient to administer their nitro heart failure so the signs and symptoms will differ depending on the extent to which the right or left side of the heart is not functioning correctly when you have right-sided heart failure it occurs when fluid backs up into the body you will see jugular vein distension ascites and peripheral edema an enlarged liver may also be present which is determined by palpation right-sided heart failure is often caused by left-sided heart failure so it is common to see the signs of both with left-sided heart failure fluid backs up into the lungs this causes pulmonary edema and shortness of breath severe shortness of breath and the hypoxia also crackles in the lungs proximal nocturnal dipsnia is characterized by a sudden attack of respiratory depress that wakes a person up at night when he or she is reclining so it's caused by fluid accumulation in the lungs and signs and symptoms include coughing feeling of suffocation cold sweats and tachycardia treatment consists of airway ventilatory and circulatory support and then there's stroke so it's the leading cause of death in older people preventable factors include smoking hypertension diabetes and afib obesity and a sedimentary lifestyle controllable factors include age race and gender signs and symptoms include altered level of consciousness numbness weakness or paralysis on one side of the body slurred speech aphasia visual disturbances headache dizziness incontinence and in the worst case a seizure hemorrhagic strokes in which broken blood vessels cause leading cause bleeding into the brain are less common and more likely to be fatal ischemic strokes occur when blood clots break the flow of blood to a portion of the brain determining the onset of the symptoms is important if the symptoms occur within the past few hours the patient can be a candidate for stroke center therapy a transient ischemic attack can present with it the same signs and symptoms as a stroke always manage the patient as if he or she is having a stroke next we're going to talk about changes to the nervous system okay and so changing in thinking speed memory and posture stability are the most common normal findings in older people the brain decreases in terms of weight so about 10 to 20 percent and volume as the person ages increasing the amount of space in the cranium and increasing the change for or change for head injuries there is about five to fifty percent loss of neurons in older people this affects the control of the rate and depth of breathing rate heart pressure hunger thirst and body temperature the performance of most of the sense organs decline with increasing age and vision vision acuity depth perception and the ability of the eyes to accommodate to light changes with age cataracts interfere with vision and make it difficult to distinguish colors and see clearly increasing the likelihood of falls and medication errors decreased tear duct production leads to drier eyes older people develop an inability to differentiate colors and have decreased night vision the inability to see up close is called prebysphobia and it can it is caused by a less elasticity of the lens a number of other diseases processes plague the vision of older adults and these include glaucoma macular degeneration and retinal detachment and then there's hearing changes in the inner ear make hearing high frequency sounds difficult changes in the ear can cause also cause problems with balance and make falls more likely so hereditary and long-term exposure to loud noises are the main factors that contribute to hearing loss when assessing your patient check for the use of hearing aids and then there's taste that taste the sense of taste can diminish because of the decrease in the number of taste buds which can cause and lead to lessened interesting interest in eating weight loss malnutrition and fatigue and touch to decrease sense of touch and pain perception from the loss of end nerve fibers okay so any person with any person who may be injured and they may not know it so decreased sensation of hot and cold also happens and then there's dementia so the slow onset of progressive disorientation shortened attention span and loss of cognitive function a chronic generally irreversible condition that causes a progressive loss of cognitive ability psychomotor skills and social skills potential causes of alzheimer's disease parkinson's disease stroke and genetic factors determine the patient's normal mental status by questioning family members or friends evaluate history risk factors and current medications the patient might exhibit loss of cognitive function patients may have short and long term memory problems and decreases attention span or they may be able to perform their daily routines they also may show a decreased ability to communicate and appear confused and then there's delirium so this is a sudden change in mental status consciousness or cognitive processes it's marked by the inability to focus think logically and maintain attention it affects 15 to 50 percent of hospitalized people aged 70 and older usually it's a result of a reversible physical ailment such as a tremor fever or some type of metabolic cause it's important to look and think um about histories okay so intoxication or withdrawal from alcohol withdraw from some sedative and medical conditions such as a uti bowel obstruction dehydration fever cardiovascular disease hyperglycemia hypoglycemia depression malnutrition and environmental emergencies so you want to assess and manage patient for hypoxia hypovolemia hypoglycemia and hypothermia you may see changes in circulation breath sounds motor function and pupillary response syncope syncope is you want to always assume that it's an underlying life-threatening problem until it's proven otherwise often causes uh it's caused by interruption and blood flow to the brain in neuropathy so this is a disorder of the nerves of the peripheral nervous system in which the function and structures of the peripheral motor sensory and autonomic neurons are impaired symptoms depend on whether the nerves affect our the motor sensory or autonomic and where the nerves are located okay so now let's talk about the change in the gastrointestinal system so there are some changes in the mouth and then they include the reduction in the volume of saliva with a resulting dryness in the mouth also dental loss is widespread in older populations and contributes to nutritional and digestive problems and gastric secretions are reduced as a person ages so include these changes in gastric mobility leads to slower gastric emptying the incidence of certain diseases such as bowel increases as the person grows older and blood flow to the liver declines so enzyme activity decreases so age-related changes um in the gastrointestinal system such as related to the pathophysiology include poor muscular tone of the smooth muscle in the sphincters between the esophagus and stomach and this can lead to regurgitation and often heartburn and acid reflux also have weakening of the rectal sphincter changes in the liver predispose older patients to a number of problems including blood flow to the liver it declines and there is a decreased metabolism this has a direct result an effect on how the medications may affect patients and then there's gi bleeding issues and common causes are inflammation or infection and obstruction of the upper and lower gi tract usually you'll see hemoemesis okay so bleeding that travels through the lower digestive tract usually manifests as malia and this is uh black tari stools okay so red blood usually means a local source of bleeding such as a hemorrhoid and a patient with a gi bleeding may experience weakness dizziness or syncope bleeding in the gi system can be life-threatening specific gi problems that are common in older patients are diverticulitis leading in the upper and lower gi system peptic ulcer disease gallbladder disease or a bowel obstruction when assessing patients ask about incense and alcohol use orthostatic vital signs can help determine if the patient is hypovolemic treatment consists of airway ventilatory and circulatory support the acute abdomen non-gastrointestinal complaints so in the pre-hospital setting the most serious threat of abdominal complaints and blood loss which can lead to shock and death so abdominal aortic aneurysm or aaa is one of the most rapidly fatal conditions next we're going to talk about changes in the renal system okay so age-related changes specific to kidney and include a reduction in renal function and a reduction in renal blood flow decreased bladder capacity decline in sphincter control decline in voiding senses increase in nocturnal voiding benign prostate hypertrophy so this is an enlarged prostate decreased weight of the kidney results in a loss of functioning leading to a smaller effective filtering surface and renal blood flow decreases as much as 50 percent so acute illnesses in older patients is often accompanied by electrolyte imbalance so this is a markedly decreased thirst mechanism which may cause rapid development and severe dehydration incontinence is not 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 so two major types of incontinence are distinguished there's stress and then urge so stress incontinence occurs during activities such as coughing laughing sneezing lifting and exercise and then there's urge incontinence and it's triggered by hot or cold fluids running water and even thinking about going to the bathroom the opposite of incontinence is urinary retention or difficulty urinating and men an enlarged prostate can lead to pressure on the urethra making voiding difficult bladder and urinary tract infections can cause inflammation and in severe cases of urinary tension patients may experience renal failure now let's talk about the changes in the endocrine system so a significant change occurs in older persons is a decrease in meta metabolism okay so this decrease affects the body's metabolism temperature growth and heart rate most of the signs and symptoms people experience are attributed to the process of aging and this includes slower heart rate fatigue drier skin and hair cold intolerance and weight gain they could also have an increase in secretions of antidiuretic hormone and this causes a fluid imbalance hyperglycemia and increases in the levels of norepi possibly having a harmful effect on the cardiovascular system hypersmaller hyperglycemic non-chaotic syndrome hhns is a diabetic complication in older people and occurs in more often in people with type 2 diabetes signs and symptoms of hhns and diabetic ketoacidosis often overlap these include hyperglycemia polydypsnia polyuria polyphagia dizziness confusion altered mental status and possibly seizures onset you may see changes in circulation such as warm flush skin poor skin turgor pale dry oral mucosa and a furrowed tongue the patient may present with signs and symptoms of hypotension shock including tachycardia the blood glucose level will vary in dka whereas in hhns the value is typically 600 or higher dka will present with cushmal's respirations while hhns will not treatment should include airway inflammatory ventilatory and circulatory support okay and then there's changes in the immune system so older people may be unable to develop a fever in fact may become hypothermic as a manifestation in severe systemic infections anorexia fatigue weight loss falls or changes in mental status may be the primary symptom of an 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 in that patient aging brings a widespread decrease in bone mass in women and men but especially among postmenopausal women bones become more brittle and tend to break more easily the discs between the vertebrae of the spine begin to narrow and a decrease in height between about two to three inches may occur through the lifespan along with changes in posture joints lose their flexibility and may be further immobilized by arthritic changes a decrease in motion and the amount of muscle mass often results in less strength changes in the physical abilities can affect older adults confidence in their mobility so the muscle system atrophies and weakens with age strength declines ligaments and cartilage of the joints lose their elasticity cartilage goes through degenerative change the stooped posture of older people comes from atrophy of supporting structures of the body and kyphosis occurs and this is a forward curling of the spine also called hunchback or humpback osteoporosis is a condition that affects men and women and it's characterized by that decrease in bone mass leading to a reduction in bone strength and greater susceptibility of fracture the extent of bone loss that the person undergoes is influenced by a number of factors including genetic smoking level of activity diet alcohol consumption hormonal factors and body weight osteoarthritis is a progressive disease of the joints that destroys cartilage promotes the found formation of bone spurs in the joints and leads to joint stiffness this affects several joints of the body most commonly those in the hands knees hips and spine patients complain of pain and stiffness that gets worse with worse with exertion and then there's changes in the skin so the proteins that make the skin pliable decline with age the layer of fat under the skin also becomes thinner because of the redistribution of fluids and proteins bruising becomes more common because the skin can tear more easily exocrine which are the sweat glands do not respond as readily to heat because of atrophy and causes and changes the tissues of the dermal layer of the skin and then there's pressure ulcers so these are known as bed sores and the pressure from the weight of the body cuts off the blood flow to an area of the skin with no blood flow to the skin a sore develops to prevent these ulcers take special care to pad under any bony premises and in the voids of a patient who may become immobilized for an extended period you may see these ulcers in the following various stages of development so a decubitus ulcer can be painful and cause complications such as bleeding sepsis and bone inflammation toxicology so older people may be more susceptible to toxicology because of a decreased kidney function altered gi absorption or decrease vascular flow in the liver the kidneys undergo many changes with age decreased liver function makes it harder for the liver to detoxify the blood and eliminate substances such as medications and alcohol typical over-the-counter medications used by older people include aspirin antacids cough syrups and decongestants many people believe over-the-counter medicines cannot be dangerous but these medicines can have negative effects when mixed with other herbal substances alcohol or prescription medicines polypharmia polypharmacy refers to the use of multiple prescription medications by one patient negative effects can include overdosing and negative medication interaction so medication non-compliance in older patients is also an issue and may occur because of financial changes inability to open containers and impaired cognitive vision and hearing ability and then let's talk about next behavioral emergencies okay so depression it's not a part of normal aging but rather a medical disease the common often debilitating psychiatric disorder affects millions of older americans it's treatable with medical with medication and therapy if depression goes unrecognized or untreated it is associated with a higher suicide rate in the geriatric population than in any other age group risk factors include history of depression chronic disease loss the following conditions contribute to the onset of specific depression so substance abuse isolation prescription medicine use or chronic medical conditions suicide most older adult suicide victims have recently been diagnosed with depression and have seen their primary care physician within a month before the event older men have the highest suicide suicide rate of any age group in the us older persons who attempt suicide choose a much more lethal means than younger victims and generally have diminished capacity to survive the attempt common predisposing events and conditions include a death of a loved one physical illness depression and hopelessness alcohol abuse or alcohol dependence or loss of meaningful life roles when assessing the patient who is displaying signs of depression it is appropriate to ask if he or she is considering suicide if the answer is yes the next question should be do you have a plan you need to include this information in your report okay so next let's talk about the gems triangle the gems diamond it was created to help you remember what is different about older patients and this serves as an acronym for the issues to be considered when assessing an older patient g stands for geriatric so consider the older patients are different from younger okay and so be familiar with the normal changes of aging and treat older patients with compassion and respect e stands for environmental assessment so you need to assess the environment and it can give you clues to the patient's condition and the cause of the emergency so preventative care is very important for a geriatric patient who may not carefully study the environment or maybe not realize where risks exist m stands for medical assessment so older patients tend to have a variety of medical problems and may be taking numerous prescriptions over the counter and medical herbal medications so obtaining a thorough medical history is very important and s stands for social assessment so older people may have less of a social network because of the death of a spouse family member and friend older people may also need assistance with activities of daily living so consider obtaining information pamphlets about some agencies to help older people in your area all right so let's talk about special considerations when we're assessing a geriatric medical patient okay so there could be communication issues or hearing and visual deficits and there could be an alteration in their consciousness complicated medical histories and effects of medications can also affect the assessment so now let's start in with the assessment okay and of course scene safety so geriatric patients are commonly found in their own homes retirement homes and skilled nursing facilities access to them may be hampered if their condition present prevents them from getting to the door so take note of negative and unself and unsafe environmental conditions look for clues that might explain the patient's medical history or current problem in a nursing home or residential care facility you will need to locate the patient's room and find the staff member who can explain why you are called in any case in which the patient's mental status is altered you need to find someone who can tell you the patient's history and whether the patient's behavior or level of consciousness is normal or altered mechanisms of the illness and injury so the noi can be different and difficult to determine in older people who may have an altered mental status or dementia you must ask a family member caregiver or bystander why he or she called multiple or chronic disease processes may also complicate the determination of the noi chest pain shortness of breath and an altered level of consciousness should always be considered serious so now is our primary assessment of course we need to address those life threats and determine the transport priority of our patient based on his or her medical condition and maintain a high index of suspicion for serious injuries even when mechanism of an injury might not may seem minor to in younger patients okay so as you approach the patient you should be able to tell if the patient is generally in a stable or unstable condition use the abdo scale to determine the patient's level of consciousness next is our a and b and so aging and disease can compromise the patient's ability to protect his or her airway and there's a loss of the gag reflex and normal swallowing mechanisms ensure the patient's airway is open and is not obstructed by dentures vomit fluid or blood suction may be necessary anatomic changes can also affect the person's ability to breathe effectively and loss of mechanisms that protect the upper airway such as a cough and gag reflex cause a decreased ability to clear secretions an airway and breathing issues should be treated with oxygen as soon as possible and then there's the c so poor perfusion is a serious issue in an older adult and there's changes that can negatively affect circulation so lower heart rates and weaker or irregular pulses are also common in older patients vascular changes and circulatory compromise may might lead to difficult to feel that radial pulse so circulation problems in older adults should be treated with oxygen as soon as possible and determine if a cardiac abnormality in an older patients indicate an acute emergency or a chronic condition so an acute emergency should be managed rapidly and then there's the d so our transport decision any complaints that compromise airway breathing or circulation should result in transportation of the patient as a priority patient your most important task is to determine conditions that are life-threatening treat them to the best of your ability and provide transport to priority patients older people do not have the res reserves that younger people do and they will easily decompensate consider early on if advanced life support treatment is necessary and immediate transport is appropriate and available and then there's the history taking so we need to find an account for all medications communication may be more complicated with an older adult but it's critical that you obtain a thorough patient history determination should be made early as to whether an altered mental or alter level of consciousness is acute or chronic multiple disease processes and multiple other vague complaints can make assessments complicated so take a full set of vital signs and ask yourself what's normal for the patient the chief complaint may be related to a chronic medical condition obtain a list of the patient's medications and take the medications with you to the hospital if possible transport to a facility that knows the patient's medical history if possible and the last oral intake is important in a patient with diabetes and may indicate that the patient may be high dehydrated and then your secondary assessment so your older patients may not be comfortable with being exposed protect his or her modesty and consider the need to keep your patient warm during the exam vital signs so medications such as beta blockers keep the heart rate low and prevent tachycardia commonly seen in dehydration and shock weak and irregular pulses are common in older patients circulatory compromise may make it difficult to feel a radial pulse in an older patient and other pulse points may need to be considered blood pressure tends to be higher in older patients cap refill is not a good assessment because skin changes and reduce circulation to the skin the respiratory rate should be the same rate as a younger adult but remember that the chest rise will be compromised by increased chest wall stiffness careful interpretation of pulse ox data is necessary in older patients because the pulse ox device requires adequate perfusion to get an accurate reading and then there's a reassessment so you want to reassess the geriatric patient often because the condition of an older person or older adult may deteriorate quickly recheck interventions and identify and treat changes in the patient's condition and then of course you want to document all history medication assessment and intervention information the table on the slide provides guidelines for cis for assessing geriatric patients okay now let's talk about trauma so in general the risk of serious injury or death is more common in older patients who experience trauma than younger patients conditions that increase risk and complicate the assessment of geriatric patients include a slower homeostatic compensate compensatory mechanism limited physiologic reserves and normal effects of aging on the body and existing medical conditions physical findings in an adult older adult may be more subtle and easily missed and the healing process is longer older pedestrians are more likely to have life-threatening complications after being struck by a vehicle and secondary impacts can also lead and cause serious injuries older people are more likely to experience burns because of altered mental status inattention and compromised neurologic status the risk of mortality from burns is increase when pre-existing medical conditions exist and the immune system is weakened fluid replacement is also complicated by renal compromise there is a higher mortality from penetrating trauma in older dots because of the cause especially in the case of gunshot wounds penetrating trauma can easily cause serious internal bleedings and falls are the leading cause of fatal and non-fatal injuries in older adults nearly half of fatal falls in geriatric patients result in traumatic brain injuries okay so changes in the pulmonary cardiovascular neurologic and muscular skeletal systems make older patients more susceptible to trauma the brain shrinks leading to higher risk of cerebral bleeding following head trauma and skeletal changes causes curvature of the spine that often requires additional padding during spinal immobilization and loss of strength sensory impairment and medical illness all increase the risk of falls a geriatric patient's overall physical condition may lessen the ability of the patient's body to compensate for the effects of even simple injuries and osteoporosis predisposes older patients to hip and pelvis fractures compression fractures of the spine are more likely to occur because the brain shrinks with age older patients are more likely to sustain close head injuries such as subdural hematomas acute subdural hematomas are among the deadliest of all head injuries serious injuries to the head are often missed in older patients because the mechanisms may be relatively minor other factors that predispose other patients or older patients to have serious head injuries occur include long-term abuse of alcohol recurrent falls or repeated head injuries and anticoagulation medications so then there's environmental injuries and this is changes in the endocrine system results in delayed internal internal temperature regulation heat gain and loss is further delayed by impaired circulation decreased sweat production chronic diseases medication use and alcohol use half of all deaths from hypothermia occur in older people most indoor hypothermia deaths involve geriatric patients death rates from hyperthermia more than double in older people compared to younger people people older than 85 are at the highest risk so trauma is never isolated to a single issue when you are assessing and caring for a geriatric patient let's talk about the trauma size up okay so or trauma assessment so we want to look for clues that indicate whether our patient's traumatic incident may have been preceded by a medical incident of course we have to address life threats determine the transport priority and it is recommended that older patients be transported to a trauma center when we form our general impression we need to try and get the information from someone familiar with the patient if possible use the avpoo and glass gall coma score to determine mental status older patients may have a diminished ability to cough so suctioning is important we also want to assess for the presence of dentures but do not remove them unless they are creating an airway problem and then circulation so drinking alcohol and taking anticoagulant medications can be can make internal bleeding worse or external bleeding more difficult to control older patients can more easily go into shock and patients who are hypertensive prior to injury may have a normal blood pressure when they are when they are actually in shock now we need to investigate that chief complaint we need the considerations in our assessment of the patient's condition and stability may include past medical conditions even if you're not currently or those are not currently an acute or symptomatic for those conditions our secondary assessment so physical exams should be performed on a geriatric trauma patient in the same manner as we would for an adult but we need to consider the likelihood of damage from trauma okay so any head injury can be life-threatening and when examining the chest we need to consider that breathing may be impaired we also need to look for bruising and other evidence of trauma we need to assess pulse blood pressure and vital signs cap refill again is unreliable in older adults because of the compromised circulation and remember that older people take beta blockers which will inhibit their heart rate from becoming too high to cart tachycardia as you would expect in shock and then repeat the primary assessment a geriatric patient has a higher likelihood of decompensating after trauma broken bones are common and should be splinted in the manner appropriately for the injury and just do not force kyphosis into the normal position we want to also provide blankets and heat to prevent hypothermia we need to provide psychological support as well as medical treatment and document assessment treatment and reassessment including any changes in the patient's status okay so let's talk about response to nursing and skilled facilities any calls will occur at a nursing home or skilled facility calls to these types of facilities can sometimes be challenging patients als often have an altar level of consciousness and may not be able to give you a nature of illness or mechanism of injury the most important piece of information you need to establish is what's wrong with the patient and what is different today that made you call 9-1-1 so talk to the staff who directly care for the patient on a daily basis infection control needs to be a high priority for mts when we visit these facilities mrsa infections are common among older people who are living in close quarters such as nursing home the organism can be found in ulcers feeding tubes and on dwelling indwelling urinary catheters protect your self and reduce the spread of immerse infections you should 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 many infections in the hospitals are caused by vre okay vancomycin resistance the respiratory rsv causes an infection of the upper and lower respiratory tracts the virus is also highly contagious and is found in discharges from the nose throat of an effective person you need to wear appropriate ppe and decontaminate your ambulance and diagnostic equipment okay so c diff is a bacterium responsible for most common cause of hospital-acquired infectious diarrhea healthcare workers may carry this bacterium following contact with contaminated feces typical alcohol-based hand sanitizers do not inactivate or kill c-diff contact precautions with gowns and gloves and hand-washing with soap and water after each and every patient contact is essential to prevent transmission sars cov2 is a strain of coronavirus that causes covid19 a respiratory illness that may affect older more vulnerable people especially those with pre-existing medical conditions spread from person to person through airborne droplets created by speaking coughing and sneezing next we're going to change the subject and talk about dying patients as older patients are living longer more terminally ill are choosing to die at home rather than in the hospital dying patients re receive what is called palliative or comfort care it focuses on relieving just pain and providing emotional support and comfort for the patient and his or her loved ones your interaction with a dying patient will have a long-term effect on the family so be understanding sensitive and compassionate advance directives are specific legal papers that direct relatives and caregivers about what kind of medical treatment may be given to patients who cannot speak for themselves advanced directives may take the form of a do not resuscitate order or dnr a dnr gives you permission to not attempt to resuscitate the patient from cardiac arrest for a dni order to be valid the form must be signed by the patient and legal surrogate and by one or more physicians or licensed health care providers dnr does not mean do not treat if a patient is still alive you're obligated to provide supportive measures that may include oxygen pain relief and comfort a healthcare power of attorney is an advanced directive that is exercised by the person who has been authorized by the patient to make medical decisions for him or her another type of order is a p-o-l-s-t so pulsed physician orders for sustaining treatment which gives medical orders in addition to advance directives orders may be specific to the person who has that life-threatening condition or is in frail health if there is any question regarding orders or when there are no orders written you need to initiate resuscitation okay so next let's talk about elder abuse and neglect elder abuse is defined as any action on the part of an older person family member caregiver or other associated person that takes advantage of an older person property or emotional state abuse can result from acts of commission and this is words or actions that cause harm such as verbal physical or sexual assault abuse can also result from acts of omission and that's a failure to act okay so such as denying an older person adequate nutrition or medical care elder abuse is a problem that has largely been hidden from society the definitions of abuse and neglect among the geriatric population vary victims of elder abuse are often hesitant to report the problems that law enforcement agencies or human or and social welfare personnel victims of elder abuse are often hesitant because the abused person may feel traumatized by the situation or be afraid that the abuser will punish him or her the abused person is often frail and multiple chronic medical conditions or dementia elder abuse occurs most often in women older than 75 abusers of older persons are sometimes products of child abuse themselves and the abuse is inflicted on the older person may be retaliatory most of these abusers are not trained in a particular care of older persons in environments such as nursing convalescence and continuing care centers are also sites where older people sustain physical physiological financial and pharmacological harm so assessment of an elderly abuse so be suspicious of the abuse when answers to questions about the cause of injury are concealed or avoided suspect abuse when you're not given unbelievable when you are given unbelievable answers so information that may be important in assessing possible abuse includes caregiver apathy about the patient's condition or overly defensive reaction by the caregiver to your questions or the caregiver does not allow the patient to answer or repeated visits to emergency department a history of being accident prone soft tissue injuries or unbelievable vague or inconsistent explanation of injuries so chronic pain without medical explanation self-destructive behavior eating and sleep disorders depression or lack of energy substance or sexual abuse history many patients who are being abused are so afraid of retribution that they make false statements okay so these are some categories of elderly abuse signs of physical abuse are in um inflicted bruises can usually be found on buttocks or lower back genitals or inner thighs cheeks or ear lobes neck upper lip or inside of the mouth pressure bruises caused by a human hand may be identified by an oval grab mark pinch marks or hand prints human bites are typically inflicted on the upper extremities and can cause lacerations and infections so you want to expect the patient's earlobes for indications of twisting pulling or pinching and investigate multiple bruises in various states or the appearance of being undernourished okay typical abuse and burns are caused by contact with cigarettes matches heated metal forced immersion in hot liquids chemicals and electrical power sources check for signs of neglect such as evidence of lack of hygiene poor dental hygiene poor temperature regulation or lack of reasonable amenities in the home regard injuries to the genitals or rectum with no reported trauma and evidence of sexual abuse in any patient okay so that brings us to the conclusion of the lecture of chapter 36 and geriatric emergencies and now we're just going to go through the review questions to see what we've learned okay the least common cause of death in patients over 65 is what and it's d so uh drug overdose according to the gems diamond the person's activities of daily living are evaluated during which one of those and we know that it is b limits is the social assessment condition that clouds the lens of the eyes is called we know that's called a cataract okay you're called to a neatly kept resident of an 80 year old woman who lives by herself she burned her hand on the stove and experienced a full thickness burn when we treat the patients it's important to note what are we looking for we're looking for the d so that's that slowing of reflexes and it causes delays and pain okay the slow onset of progressive disorientation shortened attention span and loss of cognitive function is and we know that's dementia okay 71 year old man with a history of high blood pressure and vascular disease presents with tearing abdominal pain oh my goodness okay heart rate blood pressure is low heart rate's high respirations are high your assessment reveals his abdomen is rigid and distended we want to consider uh what are we looking for and i think that that's an aortic aneurysm right yes absolutely so that it's that tearing abdominal pain that gives that away okay which of the following is a physiologic sign that occurs during the aging process all right so what do we got we know that that is a decline in kidney function which of the following conditions makes the elderly patient prone to fractures from even minor trauma we know that's osteoporosis right osteoporosis yes polypharmacy is a term often describe patients who takes and we know that that's multiple meds right multiple meds poly is multi-pharmacy medicines okay inflicted bruisings are commonly found in all of the following areas except um so uh inflicted bruisings are usually not found on the forearms they're they're hidden areas okay so that concludes the chapter 36 geriatric emergencies lecture um thank you for joining us today