South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Emergencies in the Elderly Patient

William E. Gandy, JD, LP
Copyright 2008, All Rights Reserved

READING MATERIAL
Hogan, Geriatric Emergencies Bledsoe, Paramedic Emergency Care, 3rd Edition Sanders, Mosbys Paramedic Textbook Tintinalli, Ruiz and Krome, Emergency Medicine 6th Edition

INTRODUCTION
The elderly (those over 65) comprise over 12% of the population of the US. The numbers of the old-old (over 75) are increasing as medicine improves the ability to prolong life. Life expectancy is increasing

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

The birth rate is declining and the percentage of elderly : youth is increasing. GERIATRICS IS THE STUDY OF ALL ASPECTS OF AGING, INCLUDING
PSYSIOLOGICAL PATHOLOGICAL PSYCHOLOGICAL ECONOMIC SOCIOLOCICAL PROBLEMS

In aging, there is a decline in every organ system, beginning at the cellular level. There is a decline in Total Body Water from around 60% of body weight to perhaps 4050% of body weight. Body fat decreases 15-30% but metabolic rate remains fairly constant Total number of body cells decreases

Every body system is affected. These processes begin early in life. The overall appearance changes: Loss of elasticity of skin Loss of connective tissue Loss of sweat glands Pigment deposition Damage from exposure to sun

Decubitus Ulcer Stage 2

Decubitus Ulcer Stage 3

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Decubitus Ulcer Stage 4

VISION CHANGES
Hyperopia (presbyopia) = farsightedness appears in many in middle age Decreased pupil size results in decreased ability to compensate for changes in light The ability to focus (accommodation) is decreased

Changes Affecting the Eyes

Clouding of lenses Cataracts Poor peripheral vision Pigmentation deposition
Arcus senilis (bluish or grayish circle that forms around the outer edge of the iris of the eye) Has no clinical significance

EYE CHANGES WITH AGING

Clouding of the lenses of the eye leads to:
Cataracts Poor peripheral vision

Cardiovascular Changes
Aging produces thickening of the walls of arteries and a lessening of the pliability of arterial walls. (arteriosclerosis and atherosclerosis). Hypertension, fibrosis and ventricular hypertrophy may result

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

HEART DISEASE
Can lead to ischemia of:
Lung Liver Bowel Kidneys Brain

RESPIRATORY CHANGES
The lungs lose some of their elasticity and surface area. Compliance is decreased. Ciliary activity is decreased.

Lung Tissue Changes from Young to Old

PULMONARY PROBLEMS
Chronic bronchitis
Productive cough every day for 90 days in a year for two consecutive years

RENAL SYSTEM CHANGES

The number of nephrons is decreased and there is less renal clearance of waste. There is decreased renal blood flow from arterial disease. There is increased risk from drug toxicity and toxins that are normally removed by kidney

Bronchiectasis
Damage to bronchioles

Emphysema
Loss of elasticity and alveoli

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Renal changes
Bladder control is lost by many, especially women
Remember the Depends ads ? Men experience prostate enlargement, and almost all have some prostate problems eventually

NERVOUS SYSTEM PROBLEMS

Aging results in loss of brain cells and loss of brain weight. Nerve conduction velocity decreases synapse time increases. Reflexes slow down Memory is affected, short term more than long term

STROKE PATIENTS
Patients exhibiting signs and symptoms of CVA are at great risk for aspiration Patients who cant talk usually cant swallow:
Reduced control of secretions = greater risk of aspiration. Review cranial nerves V, IX, X, XII

HEARING LOSS
High frequency loss is first Sense of balance can be affected

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

SKELETAL SYSTEM CHANGES

Aging results in diminished height as muscular tone fails. Osteoporosis affects women more than men, but men are also affected Many falls occur from pathological fractures rather than fractures resulting from falls Kyphosis often results

Kyphosis

GI SYSTEM CHANGES
Saliva production decreases significantly. HCl production decreases (slower digestion of food.) Bowel motility decreases. Taste buds fail. Gums atrophy and chewing becomes difficult.

PSYCHOLOGICAL AND SOCIAL EFFECTS OF AGING

The elderly often experience decreased levels of activity. There are exceptions to this: the individual who maintains a healthy lifestyle with exercise and diet, but these are the exception to the rule

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

PSYCHOLOGICAL/SOCIAL EFFECTS
Decreased activity and socialization Loss of friends and family Loss of social support These effects can also lead to:
Depression Isolation Anxiety Increased risk of suicide

LOSS OF FRIENDS AND FAMILY

As family and acquaintances die, the surviving elderly person becomes more and more alone There is less social support Abrupt changes in lifestyle and abode create great stress

ONE CONDITION LEADS TO ANOTHER

ASSESS AND COMPARE:
LEVEL OF ACTIVITY LOC VITAL SIGNS NEURO HEART LUNGS

EXERCISE!!!
You are called to a private gym to the handball court where a 70 year old man has been playing handball. He is sitting on a bench, looking very sweaty and red and leaning with his arms and head in his lap.

INITIAL IMPRESSION
What possibilities come to your mind immediately?

HISTORY
Patient says he was playing handball and became weak and dizzy. He actually fell while returning a volley but didnt hurt himself in the fall Denies chest pain Denies dyspnea Takes no meds but advil

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

ASSESSMENT
Bp 100/60, p 130, r: 30 Skin: hot, diaphoretic, red Blood glucose: 126 Neuro: A&A&O X 4; PEARLA Strength: weakness bilaterally with muscle tremors

ASSESSMENT
SENSORY: GOOD CMS IN ALL EXTREMITIES HEART: S1 & S2, Sinus tach at 130 without ectopy, Ps and Ts upright, no ST elevation or depression LUNGS: CLEAR & EQUAL BBS ABD: SOFT & NONTENDER

INTERVENTIONS WHATS YOUR IMPRESSION SO FAR?

WHAT WOULD YOU DO NOW? WHAT OTHER QUESTIONS WOULD YOU ASK?

COMMUNICATION WITH THE GERIATRIC PATIENT

PEARLS:
ASK ONE QUESTION AT A TIME GIVE TIME TO ANSWER HISTORY WILL TELL YOU WHATS HAPPENING MOST OF THE TIME ASK FOLLOWUP QUESTIONS

PROBLEMS
Eyesight
Glasses lost?

Hearing
Hearing aid lost or turned off?

Dentures
Not in? In but cant talk well with them?

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

ESTABLISH RAPPORT
Introduce yourself Touch
Shake hands but be aware of psychiatric patients who may not like it

PATIENT HAS DEMENTIA

Continually orient them Touch may be your best communication Maintain gentle contact Keep your voice soft and soothing Reassure and reorient

Reassure
If blind If deaf

ADVANCE DIRECTIVES
Limits of care: DNR vs. Do Not Treat DNR vs. Living Will Do you know the legal requirements?

Questions? wegandy@aol.com