Download • - Paramedic EMS Zone

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Elderly people constitute an ever-increasing proportion of patients presenting to
the health care system, particularly to the emergency care sector.
The health problems of older people are quantitatively and qualitatively different
from those of younger people. The special problems of older people require
special approaches.
The ageing process is accompanied by changes in physiological function. The
decrease in the functional capacity of various organ systems can affect the way in
which the patient responds to illness.
A variety of changes occur in the cardiovascular system as a person ages. The
heart hypertrophies (enlarges), arteriosclerosis (the stiffening of vessel walls)
develops, and the electric conduction system of the heart deteriorates.
A person’s respiratory capacity also undergoes significant reductions with age due
to decreases in the elasticity of the lungs and in the size and strength of the
respiratory muscles, calcification of costochrondral cartilage in the chest wall, and
musculoskeletal changes.
Older patients may experience renal system changes. Although the kidneys of an
elderly person may be capable of dealing with day-to-day demands, they may not
be able to meet unusual challenges, such as those imposed by illness. Therefore,
acute illness in elderly patients is often accompanied by derangements in fluid and
electrolyte balance.
Changes in the endocrine system may lead to diabetes and thyroid abnormalities
in older patients.
Ageing brings a widespread decrease in bone mass in men and women, but
especially among postmenopausal women. Bones become more brittle and tend to
break more easily.
Changes in the nervous system lead to a decrease in the performance of sense
organs, as evidenced by visual changes (glaucoma and cataracts are common) and
hearing loss.
Diseases of the heart remain the leading cause of death among older adults in the
United Kingdom. Heart attack is the major cause of morbidity and mortality in
people older than 65 years, and its potential for mortality increases significantly
after 70 years.
Stroke is a significant cause of death and disability in elderly people. More than
80% of all stroke deaths occur in persons older than 65 years, and stroke is the
leading cause of long-term disability at any age.
Chronic lower respiratory disease, influenza, and pneumonia remain in the top
five causes for elderly deaths.
An older patient with diabetes is at increased risk for hypoglycaemia for several
reasons: medications, inadequate or irregular dietary intake, inability to recognise
the warning signs due to cognitive problems, and/or blunted warning signs.
Delirium may be the only indication of hypoglycaemia in an elderly patient.
Older diabetics whose blood glucose levels tend to be high are prone to
hyperosmolar hyperglycaemic nonketotic (HHNK) coma. The most frequent
cause for HHNK is infection. Presentation is likely to be acute confusion with
dehydration.
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Gastrointestinal problems in elderly people include peptic ulcer disease, small
bowel obstruction due to gallstones, and stomach or duodenal ulcers (peptic ulcer
disease).
Osteoporosis is characterised by a decrease in bone mass leading to reduction in
bone strength and greater susceptibility to fracture. Osteoarthritis is a progressive
disease process of the joints that destroys cartilage, promotes the formation of
bone spurs in joints, and leads to joint stiffness.
In elderly people, delirium often replaces or confounds the typical presentation
caused by a medical problem, an adverse medication effect, or drug withdrawal.
Disorders that cause delirium may also include poisons, electrolyte imbalances,
nutritional deficiencies, and infections such as urinary tract infections and
pneumonia.
Unlike delirium, dementia is a disease that produces irreversible brain failure.
Disorders that cause dementia include conditions that impair vascular and
neurological structures within the brain, such as infections, stroke, head injuries,
poor nutrition, and medications.
The two most common degenerative types of dementia in older people are
Alzheimer’s disease and multi-infarct or vascular dementia, both of which cause
structural damage to the brain.
Elderly people are particularly prone to adverse drug reactions because of changes
in the following: drug metabolism because of diminished hepatic function; drug
elimination because of diminished renal function; body composition, including
increased body fat and decreased body water, altering the distribution of drugs
through the various body compartments; and the responsiveness to drugs of the
central nervous system.
Alcohol is the preferred substance of abuse among older persons, in whom its use
is on the rise. A much smaller but increasing segment of the older population uses
illicit drugs.
Depression in elderly patients can mimic the effects of many other medical
problems (such as dementia). Risk factors for depression in an older person
include a history of depression, chronic disease, and loss (function, independence,
or significant others).
Several factors place an elderly person at higher risk of trauma than a younger
person: slower reflexes, visual and hearing deficits, equilibrium disorders, and an
overall reduction in agility.
Most elderly trauma cases involve falls or road traffic collisions. Falls among
elderly people are evenly divided between those resulting from extrinsic
(external) causes, such as tripping on a loose rug or slipping on ice, and those
resulting from intrinsic (internal) causes, such as a dizzy spell or a syncopal
attack.
Knowing what is and what is not part of the ageing process constitutes the first
challenge in assessing elderly patients. A second challenge is that signs and
symptoms of disease may be altered from their presentation in younger patients as
a consequence of ageing.
When a patient’s chief complaint seems trivial, it may be necessary to go through
a review of systems to confirm that you are not missing important pieces of
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information. If any of the screening questions yields a positive answer, follow up
with further questions.
The physical examination of older patients can be difficult. Poor cooperation and
easy fatigability may require that you keep manipulations of the patient to a
minimum. You may have to peel many layers of clothing off elderly patients to
perform an adequate examination.
Infections in older people can be severe and dangerous. Consider sepsis whenever
you see a hot, flushed patient who is also tachycardic and tachypnoeic.
Elder abuse is any form of mistreatment that results in harm or loss to an older
person. Five types of abuse are distinguished: physical, sexual, emotional,
neglect, and financial.