Geriatric Patient CHAPTER INTRODUCTION CHANGES OF NORMAL AGING. Thomas V. Caprio Manish N. Shah

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1 CHAPTER 41 Approach to the Geriatric Patient Thomas V. Caprio Manish N. Shah INTRODUCTION The older adult (age 65) population is the fastest growing segment of the U.S. population. In 2000, 35 million older adults lived in the United States and comprised 15% of the population. The Census Bureau estimates that this number will double by 2030 to 70 million, and older adults will comprise 20% of the U.S. population. 1 This rapid increase in the number of older adults will significantly affect prehospital providers because older adults use EMS services at a rate significantly greater than others. A recent study using the National Hospital Ambulatory Medical Survey found that EMS transported an average of almost 6 million older adults each year between 1997 and 2000, resulting in an average transport rate of 167/1,000 population. 2 This rate was more than four times greater than the transport rate for younger patients (39/1,000 population). These data do not include patients treated and then not transported, thus underestimating the total number of requests for EMS assistance from older adults. Assuming that use rates remain constant, EMS must prepare for a significant increase in the number of older adult patients requesting assistance. By 2030, EMS will likely transport 12 million older adults per year, and older adults will comprise approximately half of the EMS call volume. EMS leaders must ensure that the EMS system is prepared for this massive expansion in EMS care delivered to older adults. CHANGES OF NORMAL AGING The physiologic changes of normal aging are important considerations in the approach to the geriatric patient by EMS. It is important to understand that aging itself is not a disease. The older adult population presents with a wide variation in health status, ranging from those with functional limitations from chronic illnesses to those who continue to function without significant decline in cognitive or physical capacity. It is important to keep in mind that successful aging with minimal impairment from chronic disease and avoidance of serious illness is becoming more common as the population shifts to older age groups in the United States. At the same time, we are also confronted with a significant number of older adults living with profound comorbid illness and reduced ability to function. One way to look at aging and illness is to consider that as life span increases, there are greater opportunities to accumulate a number of medical diagnoses and chronic conditions. The dramatic improvements observed in survival with infectious diseases, cardiac conditions, and cancer have allowed the population to live to older ages, but many older adults experience lifelong issues of chronic disease management. With older age comes an increased risk of developing certain conditions such as dementia and cancer. Age should be viewed as a risk factor, but not sufficient in and of itself as causing disease. Aging produces a diminished physiologic capacity; therefore, older adults may not have the same functional reserve in organ systems to recover from injury or illness. Even healthy and active older adults may need prolonged periods to recover from acute illness or trauma due to this reduced physiologic capacity as a result of aging. There are normal and predictable physiologic changes that occur with normal aging. Skin becomes thinner and less elastic with a reduction in subcutaneous fat, making it more susceptible to trauma and infection. The appearance of wrinkles and variations in pigmentation result from aging and the lifetime accumulation of 450

2 sun exposure and cellular damage. All of these changes in skin have an impact on EMS because trauma patients can suffer skin tears, pressure ulcers can form more easily when patients are on backboards, and ALS providers can encounter more difficulties establishing IV access. Older adults are more susceptible to problems with temperature regulation due to the changes in subcutaneous fat, reduced sweating capacity, and changes to the central nervous system that reduce the sensation of thirst and alter the compensatory regulations to maintain core body temperature. Hyperthermia and dehydration are significant concerns during periods of prolonged heat exposure. Hypothermia can occur rapidly as core body temperature drops, and responses such as shivering may be delayed. These physiologic and anatomic changes mean that EMS providers must always consider temperature abnormalities in older adults even after short periods of time in hot or cold environments and must intervene as appropriate. Hormone levels progressively decline with age, including growth hormone, estrogen, and testosterone. Postmenopausal women become more susceptible to bone loss, cardiovascular disease, and other physiologic changes due to the declining levels of estrogen. Both men and women are at increased risk for the development of fractures, especially vertebral and hip, due to the bone loss and remodeling that occur with advancing age. The spine itself undergoes changes, often with shrinkage of intravertebral discs resulting in a small loss of height, kyphosis, decreased chest wall volume, and reduced flexibility of the spinal column. There is a predictable reduction in pulmonary and cardiac function with older age, which is a clinical concern when an older adult is physiologically stressed from illness or trauma. Cardiac arrhythmias are more common in older patients, as well as stiffening of arterial walls and heart valves. This can result in heart murmurs, irregular pulses, and delayed compensation for changes in blood pressure. Lung volumes also change with aging, resulting in a reduced capacity to compensate during periods of respiratory illness or distress. Weakening of the muscles surrounding airways can result in wheezing during periods of rapid or deep breathing. Renal function undergoes a slow but progressive reduction with aging, making it necessary to carefully consider reduced dosing of medications that are cleared by the kidney. Sensory changes are common with reduced visual acuity from cataracts, hearing loss from lifetime noise exposure, and reduced peripheral nerve sensation, especially in the extremities. TABLE 41.1 Common Changes in Normal Aging Skin is thinner and susceptible to trauma. Greater difficulty in temperature regulation. Risk of fractures from bone loss. Reduced spine flexibility and loss of height. Reduced cardiac and pulmonary reserve. Reduced renal function and drug clearance. Decline in hormone levels. Reduced vision from cataracts. Hearing loss from noise exposure. It is important to point out that memory loss and dementia are not normal processes of aging. Cognitive functioning in older adults does show some age-related changes, mainly in reduced speed in processing and retrieval of information, but memory and other cognitive abilities should remain intact with advanced age. The unfortunate reality is that conditions like Alzheimer disease and other dementias are extremely common (and increasing in prevalence); however, it is never safe to assume that an older adult has simply become senile and has a dementia diagnosis. A variety of other conditions need to be carefully considered in the evaluation of cognitive problems including depression, delirium, drug toxicity, and metabolic disorders. ASSESSMENT OF THE GERIATRIC PATIENT For EMS professionals arriving to care for the geriatric patient, the initial steps are unchanged. A primary survey should be completed, evaluating the patient s ABCs. Vital signs should be obtained and any immediate interventions necessary should be completed. A full history should be taken, including the symptoms the patient has experienced, allergies, medications (including over-the-counter and herbal medications), and past medical history. A full examination should be completed. Although not traditionally considered, an environmental assessment should also be completed because the environment can provide clues as to the extent of the disease or the precipitating factors for disease. Finally, a social history should be obtained because psychosocial issues could either be the primary reason for the request for assistance, or could precipitate or exacerbate medical issues. CHAPTER 41 Approach to the Geriatric Patient 451

3 Communication with older patients is the key in performing an effective assessment. A common error made by many medical professionals is to assume that an older patient is deaf, has dementia, or is otherwise unable to communicate or participate in medical evaluation or care. This can represent a form of ageism as providers make rushed judgments based on preconceptions or personal bias regarding aging. It is not uncommon for medical personnel in any care setting to rely on family members of older patients to contribute collateral information regarding current illness or medical history. However, this often comes at the cost of speaking exclusively to others and entirely excluding the older patient. The general rule of thumb when providing care to older patients is to always speak to the patient first and then establish his or her level of understanding and participation. Use a strong, clear voice, but avoid shouting as this tends to distort words and makes it more difficult to understand. If hearing aides or eyeglasses are available and practical for the patient to use in the situation, these can make a dramatic difference in communication. When obtaining the history it is important to establish the baseline cognitive and physical functioning of the patient. If EMS is responding to a patient with reported confusion or weakness, does this patient have a history of Alzheimer dementia or physical limitations from a prior stroke or other condition? It is also relevant to consider the social context of the patient: Does he or she reside in an assisted living facility, nursing home, or his or her own apartment or home? This may influence the decision to transport a patient to the hospital if there are other caregivers available to be with the patient compared with one that lives alone without support. Family members and caregivers can also provide valuable information about the patient. A report by those present during a fall at home, episode of syncope, or witnessed seizure becomes a crucial element of the medical history, and it is important to communicate this information to subsequent emergency personnel. The final area to consider is the presence of advance directives and communicating these treatment preferences and goals of care through the health system. Patient decisions regarding resuscitation, hospitalization, and appointment of healthcare agents (durable power of medical attorney) are relevant care directives for EMS personnel to quickly identify, honor, and transfer across care settings. Most states have standardized out-of-hospital do not resuscitate forms for patients that should be available for immediate review in a patient s place of residence, whether it is a home or a long-term care facility. For patients with advanced chronic or life-threatening illness, these advance directive papers may be the most important tools in guiding subsequent decision making with regard to emergency care. GERIATRIC MEDICAL CONDITIONS Cognitive Impairment Cognitive impairment is a common condition among older adults and has been shown to increase as people age. Estimates show that up to 10% of noninstitutionalized (community-dwelling) older adults suffer from it and reports estimate that approximately a quarter of older adult emergency department (ED) patients suffer from it. 3 6 A related condition, called mild cognitive impairment, has begun to be characterized. Patients with mild cognitive impairment have well-defined memory difficulties but without the functional impairment in daily activities usually associated with dementia. Some estimate that the prevalence of mild cognitive impairment may be as high as 34%, and those with the disorder may be at risk for further decline in cognitive function and eventually develop dementia. 7 Because cognitive impairment has been associated with significant morbidity and mortality, it is important to identify this condition, even in the EMS setting. 8 A recently developed instrument to assess a patient s cognitive function, particularly suited to EMS, is the six-item screener. (Table 41.2) It has been shown to have a sensitivity of 89% and specificity of 88% to identify cognitive impairment in a community sample and can be easily used by EMS professionals. 9 Depression Depression is a common problem among older adults, with studies reporting that up to 20% of community-dwelling older adults suffer from depressed mood. 10,11 Depressive symptoms are a risk factor for increased use of medical services and a risk factor for death and disability. 12,13 Thus, this could be a precipitating factor for repeated EMS use by a patient or deterioration of a patient s medical condition. Due to this increased risk of morbidity and mortality, identification of depression is critical. However, estimates suggest that fewer than one half 452 SECTION D Special Clinical Considerations

4 of depressed older adults receive the correct diagnosis or treatment. 14,11 A number of screening instruments exist for use in the outpatient setting with reasonable sensitivity and specificity to identify potential depression One instrument, the Patient Health Questionnaire-2, or PHQ-2, has been shown to be effective in identifying patients who may be depressed. This tool can be easily used by EMS because it is short and has a simple scoring scheme and excellent sensitivity and specificity for major depressive disorder (Table 41.3) Recommendations can then be provided to the ED or primary care physician to ensure that the patient is assessed for and potentially treated for depression. Falls TABLE 41.2 Six-Item Screener for Cognitive Impairment Ask the patient to repeat three words after you: apple, table, and penny. If not repeated correctly, the test cannot continue. 1. What year is this? 2. What month is this? 3. What is the day of the week? What were the three objects I asked you to remember? 4. apple 5. table 6. penny One point for each question answered correctly. Three or more errors indicate possible dementia. Callahan CM, Unverzagt FW, Hui SL, et al. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Medical Care 2002; 40(9): Falls are a leading and preventable cause of morbidity, mortality, and loss of quality of life among community dwelling older adults Among older adults, 30% fall annually and 50% fall repeatedly. 24,25 Falls result in fear, functional deterioration, and even institutionalization. Up to 25% of those who fall suffer serious physical injuries including fractures, joint injuries, and intracranial injuries, and the remainder may suffer emotional consequences The cost of hospital care for fall-related fractures in the elderly approaches $20 billion annually in the United States. 31 TABLE 41.3 The PHQ-2 Ask the patient: 1. During the past 2 weeks have you often been bothered by little interest or pleasure in doing things? A. Not at all (0 points) B. Several days (1 point) C. More than half the days (2 points) D. Nearly every day (3 points) 2. During the past 2 weeks have you often been bothered by feeling down, depressed, or hopeless? A. Not at all (0 points) B. Several days (1 point) C. More than half the days (2 points) D. Nearly every day (3 points) Scoring: Add the points from the two questions. A score greater than 2 indicates concern for major depressive disorder. Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2 Validity of a two-item depression screener. Medical Care 2003; 41(11): Medications and Drug Toxicity A common problem in geriatric medicine is the phenomenon of polypharmacy. Literally, this problem lies in the fact that many older adults are on many medications. This can also result when multiple medical providers, including specialists, are involved in a patient s care and each one has prescribed medications without the full knowledge of the patient s current medication list. The distribution, elimination, and excretion of medications can be altered with aging. As patients take an increased number of prescribed medications, the potential for adverse drug reactions and drug-to-drug interactions also increases. There are also inappropriate medications, particularly those with cardiovascular or anticholinergic side effects, that can contribute significantly to cardiac or respiratory compromise, falls, urinary problems, delirium, hospitalizations, and even death. Older patients presenting to the ED are often taking many of these potentially inappropriate medications. 32 Patients may not report medication lists accurately to EMTs, so it is important for EMS personnel to observe the environment for medications and to consider prescription, over-the-counter, herbal, and CHAPTER 41 Approach to the Geriatric Patient 453

5 dietary supplement use in the complete patient picture and potential risk for toxicity. It often is helpful to ask the patient and family members or caregivers about other medical providers prescribing medications. For example, an older patient may consider medications prescribed by a cardiologist to be different from those prescribed by the primary care physician. A patient with cognitive difficulties may find it challenging to remember when and how to take prescribed medications, especially if he or she has multiple prescriptions. This cognitive impairment places older patients at risk for errors in taking medications and increases the chance for unintentional overdose. Field personnel should look for pill-taking strategies and reminders in the patient s home, including pill boxes, calendars, and prescription bottles. An empty (or full) prescription bottle may sometimes be the only clue as to the patient s actual medication use at home. Altered Mental Status Altered mental status refers to a disturbance in consciousness and a change in the behavior of a patient. In geriatric medicine, this acute change in mental status is often referred to as delirium. Delirium usually occurs over a relatively short period of time and is marked by a reduced ability to focus, a change in cognition, and a fluctuation throughout the course of a day. Patients with delirium tend to have poor attention, are often disoriented, and have an altered level of consciousness ranging from alert, or even hypervigilant, to profound lethargy. 33 Older patients may be at risk for developing delirium simply because of their acute illness on presentation to EMS. Patients with dementia, cancer (especially brain tumors), stroke, renal or hepatic disease, and metabolic disturbances (including dehydration) are at highest risk for developing delirium. Common conditions such as pneumonia or a urinary tract infection are sometimes enough to precipitate an older patient s decline in mental status with the development of acute confusion and altered behavior. Medication side effects, drug toxicity, and overdosage of medications can also be precipitants of delirium. Cardiac Arrest Approximately one half of EMS patients suffering from cardiac arrest are older adults. The overall survival rate for all patients suffering cardiac arrest is very poor, with most studies reporting fewer than 10% of patients surviving to discharge home. 34 One challenge for field personnel is determining which patients suffering cardiac arrest should be transported to an ED and which ones should have interventions terminated in the field. Traditionally, EMS professionals have depended on direct medical oversight (DMO) communication to terminate resuscitation efforts. Recently, however, work from Morrison et al. has attempted to define a set of criteria that can be used to terminate resuscitation efforts, thereby decreasing unnecessary transports. For BLS systems, Morrison found that patients who suffer a cardiac arrest not witnessed by EMS, do not receive a shock from an AED during resuscitation, and fail to have return of spontaneous circulation in the field can have the resuscitation appropriately terminated in the field (positive predictive value 99.5%). 35 Applying these criteria to patients receiving ALS care has been reported to be 100% predictive by the same group. 36 These criteria should be considered but must be weighed against psychosocial issues related to leaving the newly deceased in the home or another setting and related to each family s response to the death. These criteria should also be weighed against local system issues related to handling of the body. Local EMS protocols should address all of these issues. SOCIAL EMERGENCIES Social issues often can be the primary reason for which EMS was requested or may be an important precipitating issue that led to the need for EMS assistance. EMS providers and their medical directors must be sensitive to these issues. Efforts must be made to recognize and address them when caring for older adults. Some of these efforts may require system changes to truly integrate EMS into the healthcare system, including contact with social service agencies, primary care physicians, and others. Medication and Alcohol Abuse Although most healthcare providers do not think of the older adult as a significant abuser or misuser of alcohol and drugs (including prescription drugs), substance abuse is actually quite common. The Substance Abuse and Mental Health Services Administration has estimated that over 17% of adults aged 60 and older 454 SECTION D Special Clinical Considerations

6 misuse alcohol and prescription drugs. 37 This can result in frequent ED visits and hospitalizations, as well as an increased risk for falls and hip fractures. Older adults are often resistant to enrollment in traditional alcohol and drug treatment programs. Because older adult medication abusers tend to be more socially isolated and less public regarding their addiction and related problems, EMS professionals may be the first to truly identify the problem when they enter the home. Elder Abuse and Mistreatment Unlike child abuse, elder abuse and mistreatment has not received much public attention. However, it is common, with studies reporting that 1 to 2 million older adults have been injured, exploited, or mistreated. 38 Elder mistreatment includes financial, psychological, physical, and sexual abuse. EMS professionals need training on the risk factors for mistreatment and ways to identify potential abuse. A number of risk factors for elder abuse have been examined and the literature is somewhat inconsistent. However, a number of risk factors that have been validated include social isolation of the older adult, dementia, and a shared living arrangement with the abuser Characteristics of the abuser that have been identified include mental illness, alcohol abuse, and dependency on the older adult. 42 Each EMS agency should have an established protocol for reporting suspected cases of abuse. This is particularly important if EMS providers are mandated by state law to report cases of elder abuse to either a central state investigative agency or a local agency. Caregiver Distress A third social emergency is sometimes indirectly identified by the EMS professionals caregiver distress and burnout. Family members and friends may provide the majority of care for older adults with medical, psychological, or behavioral problems. Over time, this can be exhausting and lead to significant stress if the family does not have sufficient social supports or opportunities for periods of respite. As such, when a request for assistance for elderly patients is made, EMS professionals should pay attention to the family members as much as the primary patient. If the primary caregiver seems to be stressed, overwhelmed, or unable to manage the patient, then he or she may also be in need of assistance. A caregiver may also feel a personal sense of failure if a loved one becomes ill under their care, adding to the perceived burden, and the caregiver may be seeking reassurance and support. The EMS professional can help address caregiver needs by reporting information to the ED providers, calling family or friends to provide further support, and by being a calm and professional presence during the care of the patient. SPECIAL CONSIDERATIONS There are a number of special considerations that EMS leaders must acknowledge and address in their systems. EMS professionals may need special equipment to care for older adults. Padding at the upper back is needed to properly stabilize and transport older adults with kyphosis. Padded backboards are needed to prevent the rapid development of decubitus ulcers, which can commonly develop in older adults during even short treatment and transport times. Protocols that require the use of backboards only when necessary and appropriate are important considerations. Proper temperature control mechanisms and blankets are needed to prevent hypothermia or hyperthermia, for which older adults are at significant risk. Electronic medical records, preferably integrated through a regional health information organization, would be of particular benefit because older adults tend to have a number of comorbidities and medications, and having these data readily available can result in improved care. The medical and social condition of older adults who refuse transport to a hospital need to be considered carefully before allowing them to sign off. Research has shown that approximately half of older adults cared for by EMS and transported to the ED are admitted to the hospital, and also that older adults experience a decline in functional status after an ED visit. 2,43 Therefore, older adults are a high risk group and EMS providers should not merely accept the refusals of care, but should instead work to convince them to accept transport so they can benefit from care in the ED. Potential options to convince patients to accept transport may include speaking to a medical oversight physician or the patient s primary care physician, or involving family. If the patients persist in refusing, EMS should consider notifying the patient s primary care physician to ensure that careful followup occurs. CHAPTER 41 Approach to the Geriatric Patient 455

7 NURSING HOMES AND ASSISTED LIVING FACILITIES Long-term care facilities encompass a spectrum of services and housing options that are designed to address many of the needs of an older adult population. These facilities may include group homes, senior apartments, assisted living facilities, and nursing homes. Nursing homes remain key providers for the frailest older adults: those with complex care needs, high levels of functional dependence, advanced dementia, and those without sufficient social or financial supports to meet their needs at home. EMS is often called to evaluate and transport residents of long-term care facilities. Most commonly, these residents have experienced an acute illness, sustained traumatic injury following a fall, or exhibited a change in behavior. The transfer of appropriate information between these facilities and the hospital is often inadequate and has been recognized as a vital component in ensuring proper continuity of care for these patients. 44 All nursing homes receiving Medicare and Medicaid payments are required to maintain detailed medical documentation on residents in their facilities. These records contain lists of medical problems, prescribed medications, nursing and physician assessments, and advance directive documentation. Assisted living facilities and other senior housing centers are much more varied in the level of documentation available for their residents. It is of value for each EMS agency to collaborate with long-term care facilities in the community to improve access to information and ensure that copies of relevant documentation are readily available when patients are transported to and from the hospital. PUBLIC HEALTH Although the EMS system was originally developed primarily to care for patients with acute injuries and illnesses, 45 it is being increasingly recognized that EMS personnel can fulfill an important public health role, including preventing injuries and illnesses and helping patients maintain physical, social, and emotional function. Surveys of EMS providers in two separate studies have indicated that they believe that prevention is a core mission of EMS systems and should be implemented. 46,47 Work performed by Gerson and Shah show that EMS personnel can successfully screen older adults for preventable injuries and illnesses during emergency responses, although no studies have been done to evaluate the long-term outcomes of this screening, such as a reduction in injuries and illnesses Work performed by Mosesso et al. shows that EMS personnel can successfully participate in public health interventions such as influenza immunization for older adults and other populations during down time between emergency responses. 51,52 However, the effectiveness of the screening programs and associated intervention programs still needs to be evaluated. One obstacle to EMS personnel involvement in public health activities is the fragmentation of the U.S. healthcare system and the exclusion of the EMS system from the circle of care for older adults. Classically, EMS personnel only communicate with the ED, and no regular communication occurs with social service agencies, primary care physicians, or other providers, either to obtain information on a patient under the EMS system s care or to make referrals. This fragmentation is problematic because it prevents EMS personnel from confirming public health needs and ensuring that interventions are provided. EMS system leaders and medical directors are encouraged to work with the local medical and social service community to better integrate public health and medical care activities of the EMS system into the healthcare system, improve communications, and ensure patients receive the highest quality and safest care possible. RESEARCH Despite the large amount of clinical care provided to older adults, research focused on prehospital care of the older adult is extremely limited. 53 The research is lacking for the same reasons that EMS research in general is lacking, as detailed in the National EMS Research Agenda. 54 These issues include the lack of researchers, funding, and sophisticated information systems, as well as ethical concerns. However, as these limitations are addressed, many research questions need attention. Some of these questions are similar to those identified by the Geriatric Emergency Medicine Research Agenda Setting Process. 53 First, we must evaluate the diagnostic and therapeutic interventions provided to older adults. Most of our protocols result from research in the inpatient setting and often from research performed on younger adults. Questions related to ideal prehospital care of the trauma, septic, 456 SECTION D Special Clinical Considerations

8 cardiac arrest, and acute coronary syndrome patient must be answered. Second, we need research studies to better identify the sick geriatric trauma patient to determine which patients need aggressive prehospital care, if that care is proven effective, and which patients need transport to trauma centers. Third, we must evaluate if alterations in the process of emergency care can improve outcomes in older adults. Some examples of changes in the process of EMS care include transport to centers of excellence, such as geriatric fracture centers and stroke centers, detection of cognitive impairment, use of computer support systems, and use of geriatric-specific equipment. Fourth, we need to evaluate the public health role of EMS systems, particularly related to screening and prevention. Finally, we need to embrace the patient safety movement and rigorously evaluate patient safety risks in EMS systems such as the usability of medical devices, and evaluate systems-based interventions to ensure that safe, quality care is provided to older adults. 55 As these questions are answered, we can ensure that patients receive the best care possible. SUMMARY Geriatric patients require a thoughtful and focused approach when they are experiencing acute illness or injury. Their chronic medical conditions, functional impairments, and social settings make the older adult population among the most complex that EMS providers may encounter. At the same time, the data gathered in the home setting, treatment interventions, and transfer of information to other providers can have a profound affect on the quality of health care for the most vulnerable of geriatric patients. CLINICAL VIGNETTES Case 1 EMS is called to the home of an 85-year-old male with a complaint of confusion. You are greeted at the door by a very stressed son who is the primary caregiver for his father, who states that his dad is increasingly argumentative, threatening, and disoriented. Vital signs are heart rate of 48, blood pressure is 180/90, respiratory rate is 18, and oxygen saturation 94%. At this point, what further information would you like to know? At baseline, the patient has dementia with moderate memory problems but is normally alert and cooperative and has little difficulty with self-care needs. He takes cardiac medications and pain pills for arthritis. The son usually fills the pill boxes, but he has been out of town for a week on a business trip and when he returned yesterday, he noticed that his father appeared more confused on his arrival. What is the next step that EMS providers should address? There are a number of issues demonstrated in this case. The evaluation would include the necessary steps per EMS protocols (e.g., vital signs, blood glucose, cardiac monitoring, evaluation for signs of trauma, environmental assessment). Another consideration would include potential medication misuse or toxicity, especially because the son has not been recently supervising his pill taking. It is also important to consider issues of caregiver burnout because the son is obviously distressed by the care-giving situation, and this can also predispose to elder abuse. Signs of physical trauma may be related to unwitnessed falls during the son s absence or be indicators of physical abuse. Case 2 A 75-year-old female calls EMS for increasing shortness of breath for the last 24 hours. On arrival, she is seated in a chair without significant respiratory distress; she appears pale and slightly diaphoretic and is very hard of hearing. She denies any other complaints including cough, fever, or chest pain. She states she has a history of diabetes, high blood pressure, and knee surgery 2 weeks ago. She points to a bag of prescription bottles from the pharmacy and states she is uncertain as to what medications she should be taking. Her vital signs are blood pressure 196/110, heart rate CHAPTER 41 Approach to the Geriatric Patient 457

9 76, respiratory rate 20, and oxygen saturation 93%. What do you think has happened to this patient and what are the next steps to help her? She has difficulty getting up from her chair and becomes more short of breath with even slight exertion. You recommend to her that she be evaluated at the hospital, but she states No, I don t want to go anywhere. How do you communicate your concerns regarding her clinical status and reason with her to agree to further medical evaluation? This case suggests a number of potential causes for the patient s symptoms. Her medication compliance is likely poor as she does not have a clear understanding of what medications she should be taking. She may also be demonstrating an atypical presentation of disease, which may be common in older patients. An acute myocardial infarction, pneumonia, pulmonary embolus, or postoperative knee infection could also have precipitated her change in condition. Her hearing impairment may be contributing to the difficulties in communicating your concerns. If she has hearing aides available, it is important for her to wear them and ensure they are functioning properly. It can be helpful to speak slowly into her better ear in a low clear voice, while avoiding shouting. It is also helpful to ask her directly what her concerns about going to the hospital are and to help her reconcile these concerns. It may be as simple as ensuring that the house is locked, family members are contacted, or that a neighbor is aware to let her dog out at night before she will agree to be transported. REFERENCES 1. United States Census 2000, cen2000.html. Accessed October 5, Shah MN, Bazarian JJ, Lerner EB, et al.. The epidemiology of emergency medical services use by older adults: an analysis of the National Hospital Ambulatory Medical Care Survey. Acad Emerg Med 2007; 14(5): Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 2002; 39(3): Kakuma R, du Fort GG, Arsenault L, et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 2003; 51(4): Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 2002; 39(3): Naughton BJ, Moran M, Kadah H, et al. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med 1995; 25(6): Petersen RC, Doody R, Kurz A, et al. Current concepts in mild cognitive impairment. Arch Neurol 2001; 58(12): Witthaus E, Ott A, Barendregt JJ, et al. Burden of mortality and morbidity from dementia. Alzheimer Dis Assoc Disord 1999; 13(3): Callahan CM, Unverzagt FW, Hui SL, et al. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Medical Care 2002; 40(9): Beekman AT, Copeland JR, Prince MJ. Review of community prevalence of depression in later life. Br J Psychiatry 1999; 174: Blazer D. Depression in the elderly. N Engl J Med 1989; 320(3): Mistry R, Rosansky J, McGuire J, et al. Social isolation predicts re-hospitalization in a group of older American veterans enrolled in the UPBEAT Program. Int J Geriatric Psych 2001; 16(10): Penninx BW, Guralnik JM, Ferrucci L, et al. Depressive symptoms and physical decline in community-dwelling older persons. JAMA 1998; 279(21): Claassen CA, Larkin GL. Occult suicidality in an emergency department population. Br J Psych 2005; 186: Spitzer RL, Kroenke, Linzer M, et al. Health related quality of life in primary care patients with mental disorders. Results from the PRIME-MD 1000 Study. JAMA 1995; 274(19): Whooley MA, Avins AL, Miranda J, Browner WS. Casefinding instruments for depression. J Gen Intern Med 1997; 12(7): Rinaldi P, Mecocci P, Benedetti C, et al. Validation of the five-item Geriatric Depression Scale in elderly subjects in three different settings. J Am Geriatr Soc 2003; 51(5): Depression Management Tool Kit, Accessed November 1, SECTION D Special Clinical Considerations

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New York: American Geriatrics Society, National EMS Research Agenda, Accessed October 5, Fairbanks RJ, Caplan SH, Bishop PA, et al. Usability study of two common defibrillators reveals hazards. Ann Emerg Med 2007; 50(4): CHAPTER 41 Approach to the Geriatric Patient 459