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Chapter 36 Geriatric Emergencies Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 1 Case History You respond to a nursing home for a “heart attack.” On arrival, you find a 64-year-old female complaining of “crushing” chest pain and shortness of breath for the last 40 minutes. The patient tells you that she has had two heart attacks but does not want to go to the hospital. Her vital signs are pulse 58 and regular, respirations 24 and labored, and blood pressure 190/110. She has rales in her lungs and swollen ankles. She takes Inderal and Lasix. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2 Overview of Geriatric Patients More prone to serious respiratory and cardiovascular problems Less ability to compensate for severe illness More difficult to diagnose due to multiple illness and problems with assessment Subject to falls and serious injury with less severe mechanism of injury Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 Statistics on Aging Increased mean survival rate of older persons Declining birth rate Absence of major wars or other catastrophes Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Statistics on Aging Population over 65 years of age grows each year. Percent of population 65 years of age and over 3% in 1900 12.1% in 2000 Life expectancy 49 years in 1900 76.9 years in 2000 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Leading Causes of Death – Geriatric Population 1. Heart disease 2. Cancer 3. Stroke Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 Decline in Organ Systems with Age Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 Respiratory System Vital capacity decreases 50%. Decreased recoil of the lungs Loss of bronchiole muscle to maintain patency Air trapping from collapse of bronchiole Unchanged capillary circulation Shunting results Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Heart Stroke volume declines. Heart’s conduction system degenerates. Fewer pacemaker cells Maximum pulse decreases (220 minus age). Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 Vessels Increased peripheral vascular resistance Less elasticity Atherosclerosis More prone to embolism Decreased ability of vessels to respond to changes such as shock Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 Musculoskeletal System Decrease in total skeletal muscle weight Widening and weakening of bones Osteoporosis — increased potential for fractures Greater probability of fractures with minor mechanisms of injury Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Thermoregulatory Issues More susceptible to environment Decreased ability to respond Decreased heat production Decreased heat loss Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Dehydration/Feeding Decreased thirst Increased dependence Decreased mobility Decreased body fat and water Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Factors That Complicate Patient Assessment Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Geriatric Patient May Have Multiple Diseases Study identified average of 3.26 problems at a time in elderly men. Difficult to differentiate cause of immediate emergent problem Symptoms of chronic illness may be confused with symptoms of acute problem. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Aging Changes Response to Illness or Injury Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 Chronic vs. Acute Problems Rales may be caused by bedridden state. Do not confuse with pulmonary edema Loss of skin elasticity may give appearance of dehydration. Ankle edema may caused by varicose veins and inactivity/position. Do not confuse with congestive heart failure. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 Diminished Pain Response Elderly have decrease response to pain. “Silent” heart attacks are more common in elderly. Major abdominal complaints may be masked. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 Temperature Regulation Diminished Minimal or absent fever with severe infection Decreased shivering response Prone to environmental thermal conditions Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 Drug-Related Factors Study found 59% medication errors 26% serious medication errors May confuse directions May have multiple medications from various physicians Bring drugs to hospital whenever possible. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20 Drugs Alter Cardiovascular Function Slow pulse rate Beta blockers Calcium channel blockers Diuretics may affect body chemistry Anticoagulants may precipitate severe bleeding Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 Considerations in Taking Patient History Probe for significant symptoms. Chief complaint may be trivial. Patient may not volunteer significant information. Denial may impair objectivity. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22 Impaired Sight Increased anxiety Inability to exert control over situation Inability to see surroundings Talk to patient calmly and explain procedures. Position yourself so patient can best see you. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23 Diminished Hearing Can make obtaining history difficult for patient Don't assume patient is deaf without inquiring. Don't shout — distorts sounds if patient has some hearing Doesn't help if patient is deaf Write notes if necessary Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24 Diminished Hearing If patient can read lips, speak slowly and directly toward patient. Whenever possible, verify history with reliable friend or relative. Seek assistance from these individuals to communicate with patient. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25 Diminished Mental Status Patient often confused and unable to remember detail. Noise of radios, ECG, strange voices add confusion Do not assume senility is cause of delirium, confusion, distractibility, restlessness, excitement, or hostility. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26 Diminished Mental Status Does mental status represent a change from normal? Alcoholism is more common in elderly. Patient may deny alcoholism. Verify with family. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27 Past Medical History and Medications May be complicated Try to determine what is significant. Obtaining medication history is important. Usually taking multiple drugs Medication errors and noncompliance are common. Find all drugs and take to hospital with patient. Try to establish old vs. current drugs. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28 Information from Environment Attempt to verify patient history with reliable family/neighbors. Observe surroundings for indication of patient’s ability to care for self. Social services Home care Psychiatric care Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29 Information from the Environment Observe for evidence of drug/alcohol ingestion. Be conscious of potential for heat-related disorders. Look for Medical alert tags Vial of life Observe for signs of violence/abuse. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30 Considerations During Physical Examination Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31 Physical Examination Patient may be easily fatigued. Commonly wear excessive clothing Breath sounds Motor examination May hamper examination Explain actions clearly before initiating exam. Important in patients with diminished sight Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32 Physical Examination Patient may minimize or deny symptoms. Fear of being bedridden, institutionalized, or losing selfsufficiency Peripheral pulses may be difficult to evaluate because of arteriosclerosis. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33 Psychosocial Issues Fear of death Lack of family support Sensitivity to loss of independence Potential for suicide Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34 Social and Emotional Factors Denial of serious illness Fear of loss of independence Fear of dying May increase possibility of denial response Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35 Communication Barriers Avoid overfamiliarity. Avoid tendency to treat like a child. Provide sincere empathetic approach. Win confidence and cooperation. Compassion and patience are key. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36 Common Presenting Problems Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37 Fatigue and Weakness Chronic vs. acute onset Cardiovascular disease CHF Bleeding Dysrhythmias Respiratory illness COPD Pneumonia Cancer Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38 Dizziness and Fainting – CNS Causes Stroke or TIA Flexion of carotid arteries Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39 Dizziness and Fainting – Cardiovascular Causes Postural fainting Slowed vessel and pulse response Increased vascular rigidity Drugs preventing compensatory mechanisms Abnormal heart rhythms Slow heart rates Rapid heart rates Bleeding conditions GI bleeding Aneurysms Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40 Major Causes of Falls General inattentiveness May trip over objects May fall down stairs Fainting Note chronology of events. Did fall cause symptoms? Did symptoms cause fall? Posture maintenance Loss of ability to regain balance Common to small children and elderly Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41 Fractures Due to Osteoporosis Minimal mechanism of injury is likely to cause a fracture. Maintain a high index of suspicion. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42 Headache Migraines and tension headaches are less common in elderly. Take headache complaint very seriously. Consider serious cause of headache. Subdural hematoma Hemorrhagic stroke Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43 Dehydration Elderly are more prone to dehydration. Decreased kidney function Less fluid intake due to mobility Diuretic therapy Check for signs of dehydration. Dry skin turgor Dry oral mucosa Sunken eyes Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44 Thermoregulatory Problems Most common in infants and persons over 75 years Lessened ability to regulate heat production and heat loss Decreased basal metabolic rate Decreased ability to shiver Effects of medications Lessened ability to detect heat or cold Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45 Hypothermia Rarely self-reported Reliance on EMT to note on examination Need not be extreme environment May be complicated by drugs and alcohol Major causes Falls on ice and remains immobile for period time Falls at home and left undetected by others for a long period of time Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 46 Heat Emergencies Need not occur in outdoor environment May be bedridden Less ability to lose heat Signs and symptoms Apathy Weakness Fainting Environmental clues Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 47 Depression Suicide is increased among elderly white men in U.S. Depression may mimic senility/organic brain syndrome. May inhibit patient’s cooperation Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 48 Depression Patient may be malnourished, dehydrated, overdosed, and/or contemplating suicide. May simply be imagining physical ailments for attention Question about drug ingestion and suicidal thoughts if appropriate. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 49 Summary Become familiar with the common ailments associated with aging. Consider the key differential diagnoses when presented with a geriatric patient. Be aware of the special considerations associated with communicating with the geriatric patient. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 50 Summary Maintain a systematic approach. Avoid overlooking significant problems. Be conscious of reduced ability to compensate for serious illness. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51
