Geriatric Emergencies. Lesson Goal. Lesson Objectives 9/10/2012. Introduce ways geriatric patients differ from other patients

Transcription

1 Geriatric Emergencies Lesson Goal Introduce ways geriatric patients differ from other patients Physiologic changes of aging Communication issues Effects of medications Common fears of elderly patients Lesson Objectives Explain normal physiologic changes that occur with aging Discuss common fears geriatric patients may have about obtaining health care Discuss communication skills that should be used with an elderly patient 1

2 Lesson Objectives Describe changes you may need to make when assessing an elderly patient Describe common medical emergencies that occur in the elderly Discuss common traumatic injuries that occur in the elderly Lesson Objectives Explain how medications can affect patient presentation Discuss changes EMT may need to make in managing an elderly patient Describe signs of abuse of an elderly patient Introduction Geriatric patients frequently require medical care and make up the fastest growing segment of society Understand unique characteristics of geriatric populations in order to interpret assessment findings and history correctly 2

3 Physiologic Changes Age-related physiologic decline begins around age 30 By age 60, as much as 30% of organ function may be lost Maximum life span is estimated to be years, but most people do not reach this because of the effects of disease Respiratory System Chest wall loses elasticity & ability to expand fully Alveoli in number & surface area tidal volume & vital capacity; dead space & residual volume Respiratory rate may normally be >20/min because tidal volume is smaller Respiratory System Diminished ability to compensate for respiratory distress by respiratory rate (already doing so to maintain normal minute volume) Residual volume can lead to carbon dioxide retention with confusion, altered mental status, & respiratory acidosis Spinal curvature lung capacity 3

4 Cardiovascular System Elasticity of heart Efficiency of circulation Stroke volume Cardiac output Ability to compensate Cardiovascular System ~80% of elderly patients have atrial fibrillation Ineffective contraction of the atria can cardiac output and lead to stroke or pulmonary embolism Cardiovascular System Blood vessels lose elasticity Ability to compensate for sudden changes in BP or blood loss Patients may become lightheaded with sudden movement Atherosclerosis Can result in inability to provide blood to organs during times of need risk of heart attack & aortic aneurysm 4

5 Changes in the Skin Elasticity Subcutaneous tissue Muscle atrophy Sweat & oil glands Temperature regulation Sensation Skin becomes very fragile Nervous System Changes Cognition not normally affected until >70 y/o Earlier changes are suspicious for dementia Brain atrophy speed of neural impulse transmission Sensory Changes Hearing Hearing loss at the higher frequencies generally begins in 5 th decade of life Vision visual clarity Smaller pupils; difficulty seeing in dim light peripheral vision 5

6 Sensory Changes Position yourself directly in front of patient and speak in normal tone of voice If patient has eyeglasses or hearing aid, transport them with him/her Thermoregulation Number & effectiveness of thermoreceptors Muscle mass leads to less effective shivering & heat generation Elasticity of blood vessels = vasoconstriction & vasodilation Impaired heat conservation & dissipation Immune System Body s ability to fight infection declines with age because of function of immune system Septic shock resulting from infection, often of urinary tract, is a common cause of death in elderly 6

7 Musculoskeletal System Loss of bone mass = weakened bones Vertebral disks flatten Decrease in height Kyphosis Muscles atrophy; tendons lose elasticity Muscle fatigue can occur quickly Assessment Assessment of geriatric patient is same as for other patients, as long as physiologic differences are taken into account Assessment: Scene Size-Up In addition to assessing for scene safety, assess scene for clues of underlying complaint If call is at residence, observe patient s living conditions & overall status Can provide valuable insight into patient s general health condition & possible causes of current distress 7

8 Assessment: Initial Assessment Initial assessment Determine immediate life threats and determine nature of call General impression Does patient acknowledge you? Is he/she well groomed? Is there obvious respiratory distress? Is patient leaning forward clutching the chest? Any obvious signs of hemorrhage or other injury? Assessment: Mental Status You may need to alter approach to determining patient s awareness of person, place, time, and situation If patient is unable to answer questions, ask family members, caregivers, and others familiar with patient Airway Cough and gag reflexes diminish with age Sensitivity of hard palate diminishes with age, which may impair ability to recognize size of bite of food Muscles of upper airway weaken, which can allow tongue to occlude airway Dislodged dentures can cause complete airway obstruction 8

9 Breathing Respirations may be shallower, with minimal chest rise Normal respiratory rate (12 20) can result in inadequate oxygenation Auscultation with stethoscope can help determine adequacy Assess ability to speak in complete sentences & use of pursed-lip exhalation Circulation Irregularly irregular pulse due to atrial fibrillation is not unusual Heart rate may be slower and pulse weaker Compare pulse bilaterally Circulation Elderly patients have less ability to compensate for blood loss May have normal pulse and respiratory rates despite blood loss Baseline BP may be higher than normal BP of 120/80 may indicate hypotension 9

10 History, Physical Exam & Ongoing Assessment EMT should be aware of normal physiologic changes of aging & effects on physical exam Reporting Symptoms Elderly patients may underreport or fail to report symptoms Believe aches & pains are normal part of aging pain sensation; medications can complicate Patient may have vague rather than specific complaints Patient may have fears about health care and may view hospital as place where people go to die Medical Emergencies Some of the more common situations include: Altered mental status Chest pain Respiratory emergencies Abdominal pain Vague, nondescriptive complaints 10

11 Altered Mental Status Typically, no decline in cognitive processing occurs <70 y/o Recent memory generally is affected before memory of distant past Determine whether onset was sudden or gradual Altered Mental Status Can be caused by: Hypoglycemia or hypoxia Both are quickly and easily corrected Chronic CO 2 retention Medications Search for treatable causes of AMS & treat as appropriate Altered Mental Status Dementia progressive condition that presents with significant loss of memory Personality changes Impairment of >1 other cognitive functions Abstract thinking Judgment Language Alzheimer s disease most common form of dementia 11

12 Altered Mental Status Delirium Rapid onset May result in: Delusions Hallucinations Misinterpretations Many causes Often reversible with correct diagnosis & treatment Causes: MI Angina Pneumonia Pulmonary embolus Chest Pain Determine whether patient had similar pain in past & how current pain compares Pain that does not respond to NTG, is more severe, or is different from usual pattern is indication of MI, not angina Respiratory Emergencies May be chronic If problem is chronic, determine what changed that prompted call to EMS Remember that, due to decreased pain sensation, shortness of breath may be patient s only complaint during MI 12

13 Abdominal Pain Often indicates more emergent situation than in younger patients Causes: AAA Bowel ischemia Intestinal obstruction GI bleeding Ensure transport to facility with immediate surgical capability Vague Complaints Vague complaints may be only presenting symptom of serious medical emergencies in elderly Generalized weakness, dizziness, or malaise Syncopal episode Never dismiss vague complaints in the elderly as minor or insignificant! Traumatic Emergencies Trauma a leading cause of death in the elderly Several conditions predispose the elderly to traumatic injuries Pre-existing diseases mortality in trauma 13

14 Traumatic Emergencies Aging & medications reduce ability to compensate for blood loss & shock Expected signs & symptoms may not be present despite significant blood loss Traumatic Emergencies Spinal immobilization can be challenging Kyphosis Exacerbation of cardiac & respiratory problems Falls Common cause of traumatic death in the elderly Determine not only what injuries were caused by fall, but also why patient fell Ask patient if he/she had simple fall or if any medical symptoms were associated with fall Treat medical condition and any injuries caused by fall 14

15 Head Injuries Brain atrophy increases risk of subdural hematoma Hematoma may form slowly, resulting in minimal immediate signs & symptoms Chronic subdural hematomas can manifest with initial signs & symptoms months after seemingly minor fall or MVC Abuse Exact incidence is unknown Types of abuse Physical Emotional Financial Abuse Signs may be missed Living conditions Pattern injuries History Behavior around caregivers Caregivers behavior 15

16 Abuse Characteristics of abused patients Women >75 y/o Multiple medical problems, including dementia Incontinence Sleep disturbances Abuse Characteristics of abusers Commonly live with victim Were abused as children Substance abuse problems Financial & employment difficulties >50 y/o Often spouse or daughter-in-law Abuse Report suspected abuse according to state laws Report findings and observations objectively Statements made by patient should be written verbatim and enclosed within quotation marks 16

17 Summary Most EMTs will frequently encounter elderly patients, and they must be aware of these patients special circumstances & needs A number of physiologic changes both predispose the elderly to medical emergencies and trauma, and make these conditions more difficult to recognize and treat 17