Download Chapter 44: Geriatric Emergencies

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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 aging process is accompanied by changes in physiologic function. The decrease in
the functional capacity of various organ systems can affect the way in which the patient
responds to illness.
 A person’s respiratory capacity 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.
 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.
 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.
 Digestive system changes include a decrease in taste buds and a reduction in saliva and
gastric secretions. These changes may interfere with the enjoyment of food, leading to
malnutrition in elderly people.
 Geriatric patients may experience renal system changes. Although the kidneys of an
elderly person may be capable of handling 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.
 Nearly every function of the immune system is affected by aging. Older persons are
therefore more prone to infection and secondary complications than younger people.
 Changes in the integumentary system include thinner skin and loss of elasticity, allowing
skin to be torn easily and more bleeding to occur.
 Aging is accompanied by a progressive loss of homeostatic capabilities. A specific illness
or injury in elderly people is more likely to result in generalized deterioration.
 Aging 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.
 Knowing what is and what is not part of the aging process constitutes the first challenge
when you are 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
aging.
 The GEMS diamond was designed to assist the prehospital professional in the assessment
and treatment of elderly patients. It can be integrated into the patient assessment process
and it will help you to form a general impression of your patient.
 Whereas the primary assessment addresses immediately life-threatening pathologic
problems, the secondary assessment includes a systematic assessment of the patient that
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may include a full-body examination or a focused assessment on the body part or body
system specifically involved.
The physical exam of older patients can be difficult. Poor cooperation and easy
fatigability may require that you keep manipulations of the patient to a minimum.
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.
Diseases of the heart remain the leading cause of death among older adults in the United
States. Heart attack is the major cause of morbidity and mortality in people older than 65
years, and its potential for mortality increases significantly in people older than 70 years.
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 neurologic 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
disease and multi-infarct or vascular dementia, both of which cause structural damage to
the brain.
Gastrointestinal problems in elderly people include peptic ulcer disease, small bowel
obstruction due to gallstones, and stomach or duodenal ulcers (peptic ulcer disease).
The most common hospital-associated infection to cause sepsis in the United States is
urinary tract infections (UTIs).
A geriatric patient with diabetes is at increased risk for hypoglycemia for several reasons:
medications, inadequate or irregular dietary intake, inability to recognize the warning
signs due to cognitive problems, and/or blunted warning signs. Delirium may be the only
indication of hypoglycemia in an elderly patient.
Older patients with diabetes whose blood glucose levels tend to be high are prone to
hyperosmolar nonketotic coma (HONK), also called hyperosmolar hyperglycemic
nonketotic coma (HHNC). The most frequent cause for HONK/HHNC is infection.
Presentation is likely to be acute confusion with dehydration.
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 geriatric 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).
Osteoporosis is characterized by a decrease in bone mass leading to reduction in bone
strength and greater susceptibility to fracture. Osteoarthritis is a progressive disease
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process of the joints that destroys cartilage, promotes the formation of bone spurs in
joints, and leads to joint stiffness.
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 geriatric trauma cases involve falls or motor vehicle crashes. 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.
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.
Hospice care allows people with terminal illnesses to receive palliative care in their own
homes. You will be involved with end-of-life care for many patients.